Article Text

PDF
Trypan blue-guided trabeculectomy revision
  1. K N Rajkumar,
  2. H J Bunting,
  3. A K Patel
  1. Bridgend Eye Unit, Princess of Wales Hospital, Bridgend, UK
  1. Mr K N Rajkumar, Bridgend Eye Unit, Princess of Wales Hospital, Coity Road, Bridgend CF31 1RQ, UK; rajkumarkadaba{at}hotmail.com

ABSTRACT

A patient with primary open angle glaucoma and a previous trabeculectomy presented with choroidal detachments 3 weeks following bleb needling. Bleb exploration was carried out with the use of trypan blue 0.1% injected into the anterior chamber. Dye was noted to appear beneath the conjunctival bleb delineating the area of needling. Exploration of the scleral flap revealed a raised edge responsible for over-drainage that was stitched. A single sclerotomy was made and straw-coloured choroidal transudate was drained.

To view the full report and accompanying video please go to: http://bjo.bmj.com/cgi/content/full/92/4/465/DC1

All videos from the BJO video report collection are available from: http://bjo.bmj.com/video/collection.dtl

Statistics from Altmetric.com

  • Video Report

    View Video Collection

    K N Rajkumar, H J Bunting, A K Patel
    Bridgend Eye Unit, Princess of Wales Hospital, Bridgend.

    Correspondence: Mr K N Rajkumar Email:
    Email: rajkumarkadaba@hotmail.com Bridgend Eye Unit, Princess of Wales Hospital, Coity Road, Bridgend, CF31 1RQ. Tel: 01656 752752; Fax: 01656 754156.

    Date of acceptance: January 25th 2008

    A patient with primary open angle glaucoma and a previous trabeculectomy presented with choroidal detachments three weeks following bleb needling. Bleb exploration was carried out with the use of trypan blue 0.1% injected into the anterior chamber. Dye was noted to appear beneath the conjunctival bleb delineating the area of needling. Exploration of the scleral flap revealed a raised edge responsible for over-drainage which was stitched. A single sclerotomy was made and straw-coloured choroidal transudate was drained.

    View Video: Fast connectionView Video: Dial up connection

    Note: This video is best viewed in Quicktime

    Introduction

    This case describes the use of trypan blue in a pseudophakic patient undergoing drainage of a choroidal effusion. The use of trypan blue in ophthalmology dates back more than three decades.1 It is used widely to stain the anterior capsule during cataract surgery and in vitreoretinal surgery to aid visualisation of epiretinal and internal limiting membranes.2-4

    Case Report

    An 85-year-old patient with primary open angle glaucoma and a previous trabeculectomy (OS) underwent bleb needling with 5 Fluorouracil due to a progressive rise in intraocular pressure (IOP). Her IOP did not respond to the needling and remained at 20mmHg during the following two weeks. She presented to the clinic three weeks post-needling with visual acuities of 6/9 OD and perception of light OS. She was noted to have a diffuse conjunctival bleb, a shallow peripheral anterior chamber and an IOP of 14mmHg in the left eye. No aqueous leak was detected. Fundoscopy revealed extensive choroidal detachments. In the absence of hypotony, a cyclodialysis cleft was suspected and gonioscopy was performed. The view of the angle however was obscured due to the shallow peripheral chamber. Her right eye was controlled on topical treatment and stable. Over the next few days the IOP in the left eye gradually reduced to 7mmHg and she developed kissing choroidals. The bleb and anterior chamber remained stable suggesting a possible ciliary body detachment. A decision to drain the choroidal effusion was made.

    Drainage of the choroidal effusion and bleb exploration was carried out with the use of trypan blue 0.1%. The dye was injected into the anterior chamber and noted to appear beneath the conjunctival bleb delineating the area of previous needling. This suggested a possible over-drainage of aqueous and exploration of the scleral flap was carried out. A raised edge of the flap was identified and thereafter secured with a 10.0 nylon suture. A single sclerotomy was made 8mm from the limbus and straw-coloured transudate was drained. Following 30 minutes of drainage, no trypan blue staining was seen within the drained fluid confirming the absence of any communication with the anterior chamber and thus excluding a cyclodialysis cleft. The small residual choroidal effusions resolved completely over the next two days and her visual acuity gradually improved to 6/9 over the next three months.

    Discussion

    Healey and Crowston have described the mixing trypan blue with antimetabolites in glaucoma surgery such that the area of treatment can be delineated.5 Its use has also been described in determining the patency of trabeculectomies during cataract surgery.6 In both these reports, no adverse reactions have been reported and the dye did not visibly persist more than 24 hours following surgery. Its persistence following staining of the anterior capsule in phakic eyes is not known, however, it may be effectively used in pseudophakic eyes as demonstrated in this case. Its use as an adjunct during drainage may be particularly useful in atypical cases of choroidal effusions. Over-drainage of aqueous or the presence of a cleft may be identified, both of which can be addressed intra-operatively.

    References

    1. 1. Norn MS. Pachometric study on the influence of corneal endothelial vital staining. Corneal thickness after cataract extraction studied by vital staining with trypan blue. Acta Ophthalmol (Copenh). 1973;51(5):679-86.
    2. Melles GR, de Waard PW, Pameyer JH, Houdijn Beekhuis W. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg. 1999 Jan;25(1):7-9.
    3. Feron EJ, Veckeneer M, Parys-Van Ginderdeuren R, Van Lommel A, Melles GR, Stalmans P. Trypan blue staining of epiretinal membranes in proliferative vitreoretinopathy. Arch Ophthalmol. 2002 Feb;120(2):141-4.
    4. Li K, Wong D, Hiscott P, Stanga P, Groenewald C, McGalliard J. Trypan blue staining of internal limiting membrane and epiretinal membrane during vitrectomy: visual results and histopathological findings. Br J Ophthalmol. 2003 Feb;87(2):216-9.
    5. Healey PR, Crowston JG. Trypan blue identifies antimetabolite treatment area in trabeculectomy. Br J Ophthalmol. 2005 Sep;89(9):1152-6.
    6. Agrawal S, Agrawal J, Agrawal TP. Use of trypan blue to confirm the patency of filtering surgery. J Cataract Refract Surg. 2005 Jan;31(1):235-7.

    Files in this Data Supplement:

    Request permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.